Failure to Provide Ordered Therapeutic Diet for Dialysis Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, diabetes, anemia, heart failure, chronic ulcers, and kidney failure, was not consistently provided with the ordered therapeutic diet. The resident, who is cognitively intact and attends dialysis three times per week, reported feeling extremely hungry after returning from dialysis. Staff interviews and record reviews revealed that although the resident was supposed to receive a chronic kidney disease diet with extra portions, there was a lack of clarity and follow-through regarding the contents and adequacy of the meals provided, particularly the lunch sent to the dialysis center. Observations showed that the resident's lunchbox sometimes contained only a sandwich, crackers, and an empty water bottle, which did not meet the ordered double portions. The kitchen manager admitted to not verifying the contents of the lunchboxes beyond checking their weight and did not open them to ensure accuracy. Both the dietician and kitchen manager were unaware of the resident's complaints of hunger and only realized after review that the resident should have been receiving additional food items. This failure to provide the prescribed therapeutic diet led to the resident experiencing hunger and not having his nutritional needs met as ordered.